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The purpose of assessment is to:
- A. Establish a database concerning the client
- B. Delegate nursing responsibility
- C. Teach the client about his or her health
- D. Implement nursing care
Correct Answer: A
Rationale: Assessment's purpose is to establish a client database, collecting subjective (e.g., pain reports) and objective (e.g., blood pressure) data to understand health status comprehensively. This informs all nursing process steps diagnosis, planning, implementation, evaluation ensuring care is evidence-based. Delegating responsibility is a management task, not assessment's goal, which focuses on data, not task assignment. Teaching clients about health occurs later, using assessment findings, not defining its purpose. Implementing care follows planning, not assessment, which precedes action. By building a detailed picture e.g., a patient's asthma triggers assessment equips nurses to address needs accurately, making it the essential first step and primary purpose in delivering tailored, effective care.
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Which of the following statement is NOT true about cultural competence?
- A. Respects client's beliefs
- B. Improves quality of care
- C. Requires the nurse to impose her beliefs
- D. Enhances communication
Correct Answer: C
Rationale: Cultural competence respects beliefs (A), improves care (B), enhances communication (D) 'impose her beliefs' (C) isn't true, as it contradicts respecting client culture, per standards. C's imposition opposes competence's goal of sensitivity, making it the untrue statement.
The nurse enters the room to give a prescribed medication but the patient is inside the bathroom. What should the nurse do?
- A. Leave the medication at the bedside and leave the room.
- B. After a few minutes, return to that patient's room and do not leave until the patient takes the medication.
- C. Instruct the patient to take the medication and leave it at the bedside.
- D. Wait for the patient to return to bed and just leave the medication at the bedside.
Correct Answer: B
Rationale: Returning after a few minutes and staying until the patient takes the medication ensures safe administration, adhering to the 'Five Rights' right patient, drug, dose, route, and time. The nurse verifies ingestion, preventing errors like missed doses or misuse, and documents accurately. Leaving medication unattended risks it being lost, taken incorrectly, or accessed by others, violating safety protocols. Instructing without supervision assumes compliance but lacks confirmation, potentially falsifying records if the dose isn't taken. Waiting briefly then leaving it bedside still neglects oversight. Returning and remaining present balances respect for the patient's privacy with accountability, ensuring the medication reaches its intended recipient at the prescribed time, critical for treatment efficacy and legal standards in nursing practice.
The nurse is teaching the mother of a child with cystic fibrosis how to do chest percussion. The nurse should tell the mother to:
- A. Use the heel of her hand during percussion
- B. Change the child's position every 20 minutes
- C. Do percussion after the child eats and at bedtime
- D. Use cupped hands during percussion
Correct Answer: D
Rationale: Cupped hands during chest percussion loosen mucus in cystic fibrosis, creating vibrations without pain, a key physiotherapy technique to clear airways. Heel strikes are harsh, frequent repositioning isn't routine, and post-meal percussion risks reflux. Nurses teach this method for effective secretion management, improving breathing and reducing infection risk in this chronic condition.
Which of the following is the appropriate nursing intervention for a patient with a terminal illness who is passing through the acceptance stage?
- A. Allowing the patient to cry
- B. Encouraging unrestricted visiting
- C. Explaining the patient what is being done
- D. Being around though not speaking
Correct Answer: D
Rationale: In Kübler-Ross's acceptance stage, patients often seek peace, preferring quiet presence over active intervention. Being nearby without speaking respects their emotional state, offering comfort without disruption. Crying aligns with earlier stages (e.g., depression), unrestricted visiting may overwhelm, and explaining procedures suits denial or bargaining. Nurses provide silent support, aligning with the patient's need for calm reflection, enhancing dignity and comfort in end-of-life care.
A client with a tracheostomy gets easily frustrated when trying to communicate personal needs to the nurse. The nurse determines that which method for communication may be the easiest for the client?
- A. Use a pad and paper.
- B. Use a picture or word board.
- C. Have the family interpret needs.
- D. Devise a system of hand signals.
Correct Answer: B
Rationale: For a tracheostomy client, a picture or word board (B) is easiest, allowing quick, clear communication without speech. Paper (A) requires literacy and dexterity. Family interpretation (C) is unreliable. Hand signals (D) need setup. B is correct. Rationale: Visual aids bypass vocal limitations, enhancing autonomy, a practical solution per speech therapy standards.